Blazing a new trail for mental health consumers: community leaders in a rapidly growing Texas county work together to promote better care for people with mental illnesses.

One afternoon each month, the conference room at Bluebonnet Trails Community Mental Health and Mental Retardation Center in Williamson County, Texas, slowly fills with a diverse group of community leaders and decision makers from a wide array of agencies and organizations. They represent a variety of perspectives, including community mental health services, social services, physical health services, county government, criminal justice, and law enforcement. They are here to address an issue that can have a profound influence on the overall functioning and fiscal health of a community: the appropriate and effective provision of services to individuals with mental illnesses.

Background

Williamson County, located north of Austin, was cited by CNNMoney.com as one of the 100 fastest-growing counties in the nation between July 2004 and July 2005. According to the U.S. Census Bureau, the county's population increased by 79.1% between 1990 and 2000. Since then, Williamson County has continued to grow, with a current population of 333,457.

With this staggering population increase, the county has experienced a rapid transition from a primarily rural area to a growing suburban/urban region with all of the problems and challenges inherent to developing metropolitan areas. According to Williamson County data, emergency medical services (EMS) calls due to mental health issues increased from 204 calls in 2002 to 606 in 2004. Emergency room visits related to mental health issues were up 43%, and local hospitals have had to provide uncompensated care. Medical and pharmaceutical expenses have escalated secondary to an increase in costs related to the number of individuals arrested requiring treatment for mental illnesses. Other issues include:

* a high percentage of under-and/or uninsured residents;

* a shortage of psychiatrists and other mental health practitioners;

* no public transportation system;

* a low percentage of Medicaid-eligible individuals, contributing to a shortage of Medicaid providers and insufficient funding for services; and

* a need for additional services in the county's rural areas.

In 2003, the Williamson County Commissioners' Court heard constituents' concerns about these issues and the resultant gaps in mental health services. In response, the Commissioners' Court created the Williamson County Mental Health Committee, which began meeting in September 2003 under the leadership of the Commissioners' Court's project manager. Over the past three years, in a region with a history of political and fiscal conservatism, this group has explored the challenges of providing services to a growing number of people presenting with mental illness. These solution-focused meetings include discussions about increased social and legal concerns prompted by the county's rapid growth, as well as how to address these issues in light of poor state government assistance (Texas rates 47th in the nation for per capita spending for mental health (1)).

Key Agencies

Mental Health Committee members include distinguished and prominent community leaders, including:

* Commissioners' Court project manager (chair);

* staff member from the office of the state senator who represents Williamson County;

* the vice-chair of the Board of Trustees for Bluebonnet Trails;

* Williamson County district attorney;

* Williamson County assistant county attorney;

* Williamson County commissioner; and

* representatives from the sheriff's office, adult probation services, juvenile justice services, the Williamson County and Cities Health District, and other agencies.

Although the Mental Health Committee now represents more than ten agencies, organizations, and stakeholders, three entities have primary responsibility for responding to people with mental illnesses in Williamson County: Bluebonnet Trails, the Williamson County Mobile Outreach Team (MOT), and the Williamson County Sheriff's Office Crisis Intervention Team (CIT).

As the local mental health authority and the safety net for individuals with serious mental illnesses, Bluebonnet Trails is contracted by the Texas Department of State Health Services (DSHS) to ensure access to services over an eight-county region with a population well over 550,000. In Williamson County, the largest of the eight counties, Bluebonnet Trails provides mental health services to more than 2,600 individuals each year. Services include crisis intervention, psychiatric and nursing interventions, intensive case management, psychosocial rehabilitation, and medication.

The MOT is a small but effective unit of county-sponsored mental health/social services professionals. This team assists persons ineligible for public mental health services who need medication, short-term housing, drug treatment, social services, and other interventions not previously available. The county has demonstrated its commitment to this approach by recently increasing the funding to allow additional staff to be hired for the MOT.

The CIT is staffed by deputies who have received specialized training and certification in mental health issues from the Texas Commission on Law Enforcement Officer Standards and Education. The officers respond to calls from the community, the county jail, and hospital emergency rooms to determine whether individuals meet criteria for a peace officer's emergency commitment. They provide follow-up to roughly 28% of the individuals they evaluate for whom they have ongoing concerns.

Responsive and Dynamic System Review

The Mental Health Committee has served as a forum for assessing barriers to services that may be a result of limited resources, accessibility issues, or cumbersome bureaucracies. In 2005, the Committee began requesting that each key agency present the experiences of specific individuals receiving services and moving through the service system. These confidential discussions have assisted all Committee members in learning more about each agency's mission, mandates, and challenges. They have encouraged accountability and have built improved relationships.

The monthly meetings have provided a unique opportunity to educate local leaders about mental illness and the cost shifting that can occur due to inadequate availability of services. As a result, the Mental Health Committee has made several recommendations to the Commissioners' Court to address service gaps.

One of the first recommendations was to create a jail mental health liaison position. With the Commissioners' Court's support, Bluebonnet Trails hired a qualified mental health professional who uses a statewide database to identify, assess, and assist individuals in Texas's public mental health system who have been incarcerated in Williamson County. This allows offenders with mental illness to receive needed psychiatric interventions, medications, and care coordination during incarceration and upon release. The Mental Health Committee also recommended the MOT's creation.

In addition to on-site, face-to-face responses to crisis calls, the CIT has been instrumental in increasing law enforcement personnel's access to mental health training in Williamson County and other municipalities. More than 80% of the Williamson County sheriff's deputized personnel have obtained mental health certification. The training, which focuses on recognizing mental illness and its potential impact in crises, stresses intervention strategies that ensure a safe community and provide the most humane and appropriate response.

Outcomes

At the beginning of FY 2005, Bluebonnet Trails overutilized its annual bed-day allocation at state mental health hospitals by 124%. Adherence to a bed-day allocation is a performance obligation under the contract between Bluebonnet Trails and DSHS, whereby overutilization risks monetary sanction. Bluebonnet Trails enhanced clinical consultation capabilities and began providing crisis respite services for individuals at risk of hospitalization. By the end of FY 2005, Bluebonnet Trails successfully reduced utilization to 87% of the bed-day allocation. Seven months into FY 2007, the Center had continued this strategy, further reducing utilization to 65% of the bed-day allocation. Based on MOT and CIT data, there were more than an estimated 700 diversions from jails and hospitals in 2006, resulting in a savings of more than $1.8 million.

The Mental Health Committee has played a pivotal role in Williamson County by:

* enhancing the capacity of health and human services providers to participate in a collaborative and creative solution-oriented process;

* engaging in group problem solving to address service coordination issues across systems;

* decreasing the number of EMS mental health-related calls by 33%;

* diverting more than 550 individuals with mental illnesses from incarceration resulting from activities or behaviors directly related to their illnesses;

* decreasing the number of psychiatric hospitalizations by more than 30%;

* encouraging the shared use of materials, personnel, office space, and other resources;

* decreasing the number of individuals with mental illnesses using hospital emergency rooms; and

* galvanizing advocacy efforts with the Texas legislature to seek improved funding for mental health services throughout the state.